Provider Demographics
NPI:1053740092
Name:MARIA MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:MARIA MEDICAL GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMRAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSOOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-988-8001
Mailing Address - Street 1:1616 N GENTRY ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-2053
Mailing Address - Country:US
Mailing Address - Phone:417-576-6713
Mailing Address - Fax:
Practice Address - Street 1:3161 N ROCK RD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-1312
Practice Address - Country:US
Practice Address - Phone:417-576-6713
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-08
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207278201Medicaid
MO151250008OtherMEDICARE